Kids Quickie 2 Se Without Seating Order Form (rev. J)

Transcript

SUBMIT Kids Quickie 2 SE - Without Seating January 2014 EIZ10 Mark For: Submitting for: Date: PO#: † Quote † Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Attention: Dealer Address: Dealer City: ST: Dealer Phone: ( Confirmation Email: ) Address: ZIP: Fax: ( Address: ) Ship To City: † Fax Confirm Via: † Email ST: Ship To Phone: ( ) ZIP: Fax: ( ) The HCPCS CODES provided are based on code verification through PDAC or our interpretation of the code definitions. The use of HCPCS CODES does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy. D Option # HCPCS Definition D Price Option # HCPCS Definition Price KIDS QUICKIE 2 SE W/O SEATING K0005 coding still applies for EIZ10 with certain sizes † 142WM08 E1238 Kids Quickie 2 SE W/O Seating $1,950.00 FRAMES Standard Frame - 250 lbs. Maximum User Weight Standard Matte Colors Frame Type Uses Rear Side Frame Depth Adj. & Depth Adj. Back † 142C116 Matte Black NC † 142FT54 Cross Brace with Seat Rails NC † 142C151 Matte Black Cherry NC † 142FT55 Cross Brace w/o Seat Rails NC † 142C152 Matte Purple NC † 142C150 Matte Electric Blue NC † 142C149 Matte Evergreen NC † 142C43 Mossy Oak Camouflage $295.00 † 142C42 Stars & Stripes $295.00 † 142C108 Zebra (Choose above base color) Std with White unless above base paint is chosen. NA w/ Black $295.00 Transit System Incl. Stabilizer Bar. N/A with Swing-Away Stroller Handles and Extension with Cross Brace with Seat Rails. † 142TO1 Transit System $315.00 Custom Frame Color Standard Colors † 142C140 † 142C2 † † Aztec Gold NC Black (Not avail as base w/Zebra) NC 142C141 Black Cherry NC 142C10 Black Opal NC † 142C38 Blue Opal NC † 142C36 Candy Blue NC † 142C14 Candy Purple Frame Width † 142W2 11" (By Upholstery) NC † 142W3 12" † 142W4 13" NC 142W5 14" NC (Avail. w/Cross Brace w/ Seat Rails Only) NC NC † 142C35 Candy Red NC † 142C142 Electric Blue NC † † 142C143 Evergreen NC † 142W6 15" $250.00 † 142C126 Glow NC † 142W7 16" $250.00 † 142C144 Green Apple NC † 142W8 17" (Avail. w/Cross Brace w/ Seat Rails Only) $250.00 † † † † † † † 142C147 142C148 142C103 142C114 142C145 142C113 142C8 Hot Sparkle Pink Mauve Pink Rootbeer Sparkle Silver Sunrise Orange Titanium Color Paint Yellow NC NC NC NC NC NC NC † 142W9 18" (Avail. w/Cross Brace w/ Seat Rails Only) $250.00 Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. 931165 REV. J Page 1 FRAME DEPTH AND BACK POST LOCATION Choose 1 or 2 2. Frame Depth and Back Post Location With Seat Rail 1. Frame Depth and Back Post Location W/O Seat Rail † 142FL1 Kids Frame (10"-16" Depth) NC Frame Length 142FD3 10" Frame Depth NC † 142FL1 Kids STD † 142FD4 11" Frame Depth NC † 142FL9 Regular NC † 142FD5 13" Frame Depth NC † † 142FD6 15" Frame Depth NC † 142FD7 16" Frame Depth NC † 142FL9 Regular Frame (12"-18" Depth) NC † 142FD3 12" Frame Depth NC † 142FD4 13" Frame Depth NC † 142FD6 15" Frame Depth NC † 142FD8 17" Frame Depth NC † 142FD9 18" Frame Depth NC Long Frame (14"-20" Depth) NC † † 142FD5 14" Frame Depth NC † 142FD6 15" Frame Depth NC CHOOSE 1 OR 2 † NC Long 142FL18 Seat Rail Length (Sling Not Included) † 142SN05 10" NC † 142SN06 11" NC † 142SN07 12" NC † 142SN08 13" NC † 142SN09 14" NC † 142SN10 15" $250.00 † 142SN11 16" $250.00 † 142SN12 17" $250.00 18" $250.00 † 142SN13 Back Post Location † 142FD8 17" Frame Depth NC † 142BL14 1" Offset From Seat Rail NC † 142FD10 19" Frame Depth NC † 142BL15 2" Offset From Seat Rail NC † 142FD11 E2201 20" Frame Depth NC DEPTH ADJUSTABLE BACK and JAY JAY Cushions (Optional) Stroller Handle (Height) † 142BP27 Depth Adj. Back Post Standard STD † 142BP28 Depth Adj. Back Post Medium NC † 142BP29 Depth Adj. Back Post Tall NC JAY Bundled Cushion † Stroller Handle Options † 142BP33 Swing Away Stroller Handles To order any JAY cushions on-chair, please see the JAY price list. Cushion name or part number must be filled out with desired width and depth 142JC20 $100.00 Cushion Name or Part # Width: Price List Depth: JAY Backs (Optional) Ordering JAYbacks on-chair, lease see the JAY price list. Requires part # JAY Bundled Backrest † 142JB02 Backrest Name or Part # Width: Price List Height: ARMRESTS † 142AA3 STD † 142AA8 † 142AA1 E0973 Ht. Adj. Locking Flip Up $250.00 † 142AM1 Desk Length (10") † 142AA7 E0973 Ht/Length Adj. Locking Flip Up $260.00 † 142AM2 Full Length (14") † 142AM1 Desk Length (10") NC † 142AA9 † 142AM2 Full Length (14") NC † 142AM1 Desk Length (10") † 142AM9 Foam Short NC † 142AM2 Full Length (14") NC Foam Long NC † Omit Armrest NC † 142AM10 Flip Up 142AA14 E0973 Ht Adj. Adult E0973 Ht/Length Adj. Kids Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. 931165 REV. J Page 2 $265.00 NC NC $265.00 NC FOOTRESTS Choose 1 or 2 1. Hanger Type (Mount With Extension Tube) 2. Hanger Type (Direct Mount Hanger † † Hanger 60° Swing-Away Hanger Elevating Hanger (Only avail. w/ alum. 142H1 142H14 E0990 Footplates or angle adj. Available on 14"-18" frame widths. N/A w/ locking angle adj. footplates or short ext. tubes.) STD † † 142E1 Short (see matrix for length) NC † 142E2 Medium (see matrix for length) NC † 142E5 Long (see matrix for length) NC † 142E12 Short ELR (ELR only) NC † 142E15 Long ELR (ELR only) NC High Mount † 142E16 K0037 $55.00 Footplate † 142F1 † 142F4 K0040 Kids Angle Adj. Footplate $185.00 † 142F3 K0040 Adult Angle Adj. Footplate (12"16"w) $185.00 † † 142F48 142F5 Composite Footplate (12"-16"w) K0040 Platform Flip Up Footplate (n/a with short ext. tubes. Only avail. With 60° 70° and 70° V) Aluminum Footplate Available w/ ELRs 80° Swing Away Hangers Front Mount (Only avail. w/ Kids or Adult Angle Adj. or 142H8 NC 90° footboard footplates) STD CHOOSE 1 OR 2 † NC 90° footboard footplates) $295.00 Extension Tube (Required for Option 1) NA elevating leg rests. Only avail. w/ adult or kids angle adj. footplates. 70° Swing Away Hangers Front Mount (Only avail. w/ Kids or Adult Angle Adj. or 142H7 † 142H6 90° Swing Away Hangers (Only avail. w/ Kids or Adult Angle Adj. or 90° footboard footplates) † 142H23 E0990 90° Swing Away ELR (Only avail. On 12"16" widths, not avail. With 8" casters) NC $295.00 Extensions (Optional) † 142E23 2" Extensions (n/a w/90° hangers & elevating leg rests) $55.00 † 142E24 4" Extensions (n/a w/90° hangers & elevating leg rests) $55.00 Footplate Type $190.00 NC † 142E23 K0040 Kids Angle Adjustable Footplate (10" - 16" W) $175.00 † 142E24 K0040 Adult Angle Adjustable Footplate (Available on 12" - 16" W) $185.00 Footrest Options † 142HL9 E0951 Heel Loops $50.00 † 142HL8 K0038 Leg Straps $35.00 Impact Guard † 142IG2 Neoprene (Only avail. With 60° 70° and 70° V) $85.00 CASTERS Caster Wheels Caster Wheels - Continued † 142CW3 4" Polyurethane NC † 142CW31 4" Micro Lighted $70.00 † 142CW5 5" Low Profile Polyurethane † 142CW7 † 142CW6 † 142CW33 † 142CW34 † 142CW35 † 142CW21 † 142CW32 5" x 1.5" Semi Pneumatic (only avail. for use in bottom fork holes) 5" Soft Roll Semi Pneumatic E2214 6" Pneumatic (Requires selection of E2215 Caster Tire Tube/Insert) 6" Polyurethane 6" x 1.5" Semi Pneumatic (only avail. for use in bottom fork holes) E2214 8" Pneumatic (Not avail. w/ 90° elevating leg rests. Not avail. w/kids frame length. Requires E2215 selection of Caster Tire Tube/Insert) 8" Polyurethane (Not avail. w/ 90° elevating leg rests or w/kids frame length.) † 142CW39 † 142CW36 † 142CW12 NC $85.00 $85.00 8" x 1.5" Semi Pneumatic (only avail. for use in bottom fork holes) E2214 8" x 2" Pneumatic (Not avail. w/ 90° elevating leg rests. Not avail. w/kids frame length. E2215 Requires selection of Caster Tire Tube/Insert) Omit Caster Wheels $75.00 $145.00 NC Caster Tire Tube/Insert STD $85.00 $85.00 Requires a selection of 6", 8" or 8"x2" Pneumatic Tire. Airless Insert (Only avail. With 8"x2" Pneumatic) $65.00 142CZ1 Caster Tube (all sizes) $20.00 † 142CS5 3/4" Longer Fork Stem Bolt † 142CS10 1-1/2" Longer Fork Stem Bolt † 142CS3 † 142CZ2 † K0064 $75.00 Caster Options NC K0073 Caster Pin Locks Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. 931165 REV. J Page 3 NC NC $195.00 AXLE AND WHEELS † † † † † † † † † † † 142AL2 142AL71 142AX1 142AX11 142AT6 142RW3 142RW74 142RW8 142RW75 142RW1 142RW54 † 142RT1 † 142RT29 Axle Plate Standard Adjustable E0959 Amputee Adjustable Axle Quick Release Quad Quick Release Anti-Tip E0971 Rear Anti-Tip Rear Wheel Type 20" Mag 20" Lite Spoke 22" Mag 22" Lite Spoke 24" Mag 24" Spoke Rear Wheel Tire E2211 Pneumatic (Requires the selection of E2212 Rear Wheel Tire/Insert) E2218 Full Polyurethane (avail w/Mag only) NC $85.00 Rear Wheel Tire Tube/Insert Requires a selection of Pneumatic E2213 Pneumatic Airless Insert E2211 Pneumatic Tube E2212 † 142RZ2 † 142RT1 † † † 142HR1 142HR4 142HR7 Hand rim Aluminum Anodized Plastic Coated Omit † † 142WL1 142WL2 Wheel Lock High Mount Push High Mount Pull † 142EH1 Extension Handle E0961 6" Pair $75.00 † Grade Aid Requires a selection of Rear Wheel Tire/Insert 142GA1 E0974 Grade Aid $150.00 STD $90.00 $80.00 NC NC $95.00 NC $135.00 NC NC NC NC NC $100.00 NC NC $85.00 $50.00 ACCESSORIES † † 142A1 142A2 Backpack Utility Pack - Black Kids Black Backpack - Zippie † 142A8 Black † † † 142A49 142A83 142A54 † † Side Guard Not available with height adj. flip back armrests 142SG4 K0108 Plastic Kids 142SG3 K0108 Plastic Regular $55.00 $50.00 Seat Pouch Miscellaneous E2207 Crutch Holder Tool Kit K0038 Extra Leg Strap $45.00 $195.00 $45.00 $30.00 $125.00 $125.00 Positioning Belt Belt 1.5" Auto Buckle w/Clamps Belt 2" Aircraft Buckle w/Clamps Belt 2" Aircraft Buckle w/Clamps 1" Dual Pull Side Squeeze Pad w /Clmp 1" Comfort Fit APB5116 † † † † † 142A141 142A117 142A118 142A112 142A814 E0978 E0978 K0108 E0978 E0978 † † 142A24 142A23 Spoke Guard K0065 Clear K0065 Black $115.00 $115.00 † † † † 142A29 142A30 142A31 142A32 Upper Extremity Support Tray E0950 X-Small (Suggested 10"-12") E0950 Small (Suggested 13"-14") E0950 Medium (Suggested 15"-17") E0950 Large (Suggested 18"-20") $250.00 $250.00 $250.00 $250.00 Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. 931165 REV. J Page 4 $70.00 $110.00 $120.00 $85.00 $120.00